GERMED 1 Flashcards
go over bmj
What things would you peform in a physical exam to ass incontience? [4]
Abdominal exam + Post-void bladder scan
– Urinary retention
External PV
– prolapse, fistula, atrophic vulvovaginitis
- Digital vagina exam to assess pelvic floor muscle strength
- Stress/ cough test (best performed with full bladder)
PR
- constipation
- cauda equina
- BPH
CNS
- neurological disease
perineal sensation (sacral nerves S2-4)
- gait disturbance/ Parkinsonism, lower limb exam (incl pedal oedema)
Which investigations would you perform for incontinence? [4]
Urinalysis
* Haematuria (bladder neoplasia)
* Glucosuria (diabetic polyuria)
* Nitrites/ leucocytes - UTI
US abdomen – hydronephrosis/ abdominal mass
Urodynamic flow studies – prior to surgery
Rarely spinal MRI (cauda equina)
How can you tx overflow incontinence? [4]
- Relieve/ treat obstruction
- Intermittent self-catheterisation
- Indwelling catheter
- Suprapubic catheters: lower rates symptomatic UTI and by-passing
Describe lifestyle [2], medical [1] and surgical [3] management for stress incontinence
Lifestyle:
- Patients should be advised to have a consistent fluid intake of around 1.5-2 litres, avoiding either excess or insufficient amounts.
Pelvic floor muscle training:
- NICE recommend at least 8 contractions performed 3 times per day for a minimum of 3 months
Medical management:
- Duloxetine
Surgical procedures:
- e.g. retropubic mid-urethral tape procedures
- Colposuspension: this is an operation that may be completed open or laparoscopically and involves lifting the bladder neck upward with stitches placed to hold it in place.
- Autologous rectus fascial sling: a sling is made from the patient’s own fascia and is used to support the urethra and the pelvic floor muscles.
Describe medical [3] and surgical [1] management for overactive bladder syndrome
Anticholinergics:
- directly relax urinary smooth muscle-> reduce involuntary detrusor contractions and increase bladder capacity
- Oxybutynin most cost-effective: advised avoid frail elderly women
- Tolterodine reduced dry mouth s/e
Review 4-weekly
- Mirabegron: agonist of beta-3 receptor in - detrusor smooth muscle (s/e hypertension)
Botulinum A
Surgery:
* Nerve stimulation: sacral nerve stimulation, percutaneous posterior tibial nerve stimulaiton
Describe how you investigate for UI? [4]
- bladder diaries should be completed for a minimum of 3 days
- vaginal examination to exclude pelvic organ prolapse and ability to initiate voluntary contraction of pelvic floor muscles (‘Kegel’ exercises)
- urine dipstick and culture: UTI can contribute
- urodynamic studies (not routinely required): Cytometry is a urodynamic test that involves the insertion of a urinary catheter and the gradual filling of the bladder. A rectal probe is used at the same time to measure pressure as the bladder fills and then during voiding. Helps to measure detrusor pressure and bladder capacity.
Intra-vesicular injection of which drug can improve urge incontinence? [1]
Botulinum toxin
What is the minimum recommended number of days that should be recorded in a bladder diary? [1]
3
QuesMed
What is the gold-standard surgical treatment for stress incontinence? [1]
Mid-urethral sling
Which medications are most likely to cause functional incontinence? [1]
Opioids and those with a sedating effect
If the incontinence is not characterized by stress or urgency incontinence, ask about: [3]
Voiding difficulty (for example straining to void, sensation of incomplete emptying) — may suggest chronic urinary retention (overflow incontinence).
Constant leakage of urine (may be intermittent if position dependent) — suggestive of a fistula (for example vesicovaginal).
Post-void dribbling, pain, urgency, frequency, recurrent urinary tract infection, vaginal discharge, and dyspareunia — consider a urethral diverticulum.
Which factors would favour that a person is suffering from delirium over dementia? [5]
Aka describe the clinical features of delirium
Factors favouring delirium over dementia
* acute onset
* attentional deficits
* impairment of consciousness: hyperalertness to stupor; may fluctuate
* fluctuation of symptoms: worse at night, periods of normality
* abnormal perception (e.g. illusions and hallucinations) - visual hallucination is almost always associated with delirium
* Emotional disturbance: agitation, fear
* Abnormal perceptions: visual or auditory hallucinations; paranoid delusions
* Sleep-Wake Cycle Disturbances: patients often experience insomnia during the night and excessive sleepiness during the day.
* Anxiety, irritability, apathy or depression are common emotional manifestations of delirium.
* Deficits in memory, particularly short-term memory, orientation and language are common
Dementia is more likely if:
- slowly progressive with limited fluctuation
- Attention is usually in tact and very early memories may be preserved
NB: can be hyper/hypo/mixed changes
ASK what they’re experiencing / feeling
Describe the diagnostic criteria used to diagnose delirium
DSM-5 criteria:
- Disturbance in awareness (e.g. disorientated to time, place, person) and attention (e.g. unable to subtract serial 7’s)
- Acute onset (hours to days), acute change from baseline, and fluctuant
- Disturbance in cognition (e.g. memory loss, misperception)
- Not better explained by a pre-existing, established, or evolving neurocognitive disorder and absence of severely reduced GCS
- Evidence of an organic cause (i.e. medical condition, medication, intoxication)
Describe what is meant by delirium [1]
Delirium refers to an acute confusional state that causes disturbed consciousness, attention, cognition & perception.
Delirium is typically acute onset and fluctuates throughout the course of the day.
Despite simple deescalation methods, patients with delirium may still pose significant psychological or physical harm to themselves and there may be risk of harm to others within the environment (e.g. patients, staff).
In these situations, the use of short-term pharmacological measures may be needed that is often referred to as rapid tranquillisation.
Name two drugs that could be used? [2]
Benzodiazepines (e.g. lorazepam)
Anti-psychotics (e.g. haloperidol, olanzepine)
The oral route should always be used in preference, but if not possible, then the intramuscular route is used
A person lacks capacity if they cannot do one or more of the following [4]
A person lacks capacity if they cannot do one or more of the following:
Understand the information relevant to the decision
Retain the information long enough to be able to make the decision
Use or weigh up information available to make the decision
Communicate their decision
Which drugs are known to causes delirium
Anticholinergics, sedatives, opioids and polypharmacy in general.
How would you differentiate delirium to pyschosis? [3]
Pyschosis:
- hallucinations are typically auditory
- Do NOT show altered level of consciousness
- Demonstrate loosening of associations or tangentiality (whereas delirium exhibit an impaired ability to maintain a coherent stream of thought due to attention deficits)
NB: pyschosis is a more specific mental health illness
Which screening tool should you use for ? delirium? [1]
4-AT
What is the underlying pathophysiological change in neurotransmitters seen in delirium? [1]
deficiencies in acetylcholine and/or melatonin availability; excess in dopamine, norepinephrine, and/or glutamate release;
Non-resolving hypoactive delirium - which pathology should you consider? [1]
How would you differentiate? [1]
Name 3 risk factors for this pathology [3]
Non convulsive status elipeticus
- differentiate using an EEG
The risk factors associated with NCSE include pre-existing epilepsy and often with poor adherence to anti-epileptic drugs (AEDs), acute systemic infection, metabolic disorders, drugs and some acute brain lesions.
Which electrolyte disturbances can cause delirium? [4]
hypercalcaemia
hyponatraemia
hypoglycaemia
hyperglycaemia
